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CARDIO > old HF, pulmonary oedema, cardiogenic shock, HTN > Flashcards

old HF, pulmonary oedema, cardiogenic shock, HTN Flashcards

1
Q

what is the definition of heart failure?

A

CO inadequate for body’s requirements despite adequate filling pressures

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2
Q

what is the pathophysiology of HF?

A 
1) reduced CO initially -> compensation 
starling effect dilates heart to enhance contractility 
remodelling -> hypertrophy 
RAS + ANP/BNP release
sympathetic activation

2) progressive decrease in co-> decompensation
progressive dilatation leads to impaired contractility + functional valve regard
hypertrophy leads to relative myocardial ischaemia
RAS activation leads to na+ and fluid retention leads to increase venous pressure leads to oedema
sympathetic excess leads to increase in afterload and decrease in CO

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3
Q

what is low output HF?

A

CO decreases and fails to increase with exertion

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4
Q

what are the cateogires of causes of low output HF?

A

1) pump failure
2) excessive pre-load
3) excessive afterload

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5
Q

what are the causes of pump failure in low output hf?

A 
1) systolic failure leads to impaired contraction 
ischaemia/MI
dilated cardiomyopathy
HTN
myocarditis

2) diastolic failure leads to imapired filling
pericardial effusion/tamponade/constriction
cardiomyopathy: restrictive, hypertrophic

3) arrhythmias- bradycardia, heartblock, tachycardias, anti-arrhythmics eg bb, verapamil

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6
Q

what are the causes of excessive preload in low output hf?

A

AR
MR
fluid overload

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7
Q

what are the causes of excessive afterload in low output hf?

A

AS
HTN
HOCM

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8
Q

what is high output hf?

A

there are higher needs which lead to RVF initially and then LVF

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9
Q

what are the causes of high output hf?

A

anaemia, AVM
thyrotoxicosis, thiamine deficiency (beri beri)
pregnancy, pagets

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10
Q

what are the causes of right ventricular dysfx?

A

LVF
co pulmonale
tricuspid pulmonary valve disease

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11
Q

what are the symptoms of RVF?

A

anorexia and nausea

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12
Q

what are the signs of RVF?

A

raised jvp + jugular venous distension
tender smooth hepatomegaly (may be pulsatile)
pitting oedema
ascites

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13
Q

what are the causes of LVF?

A 
IHD
idiopathic dilated cardiomyopathy
systemic HTN
mitral and aortic valve disease 
specific cardiomyopathies
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14
Q

what are the symptoms of LVF?

A 
fatigue 
exertional dyspnoea
orthopnoea + PND
nocturnal cough (+/- pink frothy sputum)
weight loss + muscle wasting
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15
Q

what are the signs of LVF?

A 
cold peripheries +/- cyanosis 
often in AF
cardiomegaly with displaced apex
S3 + tachy= gallop rythm
wheeze (cardiac asthma)
bibasal creps
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16
Q

what is acute HF?

A

new onset or decompensation of chronic
peripheral/pulmonary oedema
+/- evidence of peripheral hypoperfusion

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17
Q

what is chronic HF?

A

develops/progresses slowly
venous congestion common
arterial prssure mainted until very late

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18
Q

how is chronic HF diagnosed?

A

framingham criteria

2 major criteria or 1 major + 2 minor

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19
Q

what investigations woudl you do for chronic hf?

A

bloods- FBC, UE, BNP, FT, glucose, lipids
CXR
ECG
ECHO

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20
Q

what would you see on CXR for chronic hf?

A 
ABCDEF
alveolar shadowing
kerley b lines
cardiomegaly 
upper love divesion
effusions 
fluid in fissures
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21
Q

what can you see on ECG for chronic heart failure?

A

ischaemia
hypertrophy
AF

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22
Q

what can be seen on echo for chronic heart failure?

A

focal/global hypokinesia
hypertrophy
valve lesions
intracardiac shunts

global systolic/diastolic function. EF normally about 60%

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23
Q

what classification system is used for hf?

A

NYHA classification

1- no limitation of activity
2- comfortable at rest, dypsnoea on ordinary activity
3- marked limitation of ordinary activity
4- dyspnoea at rest and all activity

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24
Q

what is the primary/secondary cardiovascular risk prevention for HF?

A 
smoking cessation
decrease salt intake
weight loss/gain- dietician
rehab programme 
aspirin 
statins
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25
Q

what is the underlying cause for chronic heart failure requiring treatment?

A

valve disease
arrhytmias
ischaemia

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26
Q

what are the exacerbating factors for chronic heart failure requiring treatment?

A

anaemia
infection
increased bp

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27
Q

what treatments lower mortality in chronic heart failure?

A

ace inhibitors
bb
spironolactone

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28
Q

what is the 1st line management of chronic hf?

A

ACEi/ARB- lisinopril or candesartan. hydrazlazine + ISDN if not tolerated (watch K+ on ACE-i)

bb- carvedilol or bisoprolol.

loop diuretic- frusemide or bumetanide

29
Q

what is the 2nd line management of chronic hf?

A

specialist advice
spironolactone/eplerenone- watch K+

ACEI/ARB
vasodilators- hydralazine + ISDN- additional treatment in black people

30
Q

what is the 3rd line of chronic hf?

A

digoxin

cardiac resynchornisation therapy +/- ICD

31
Q

what other monitoring do you need to do in chronic hf?

A

BP- may be very low
renal function
plasma K+
daily weights

use amlodipine for comrbid HTN or angina
avoid verapamil, diltiazem and nifedipine - short-acting

32
Q

what invasive therapies can be done for chronic hf?

A

cardiac resynchronisation +/- ICD
intra-aortic balloon counterpulsation
LVAD
heart transplant

33
Q

what are the causes of severe pulmonary oedema?

A

1) cariogenic
MI
arrythmia
fluid overload- renal, iatrogenic

2) non-cardiogenic
ARDS- sepsis, post-op, trauma
upper airway obstruction
neurogenic- HI

34
Q

what are the symptoms of severe pulmonary oedema?

A

dyspnoea
orthopnoea
pink frothy sputum

35
Q

what are the signs of severe pulmonary oedema?

A 
distressed, sweaty, cyanosed
tachycardic, tachypnoeic
raised jvp
S3/gallop rythma
bibasal creps
pleural effusions
wheeze
36
Q

what are ddx of severe pulmonary oedema?

A

asthma/copd
pneumonia
PE

37
Q

how do you monitor the progress of severe pulmonary oedema?

A 
bp
hr 
rr 
jvp
urine output
abg
38
Q

what is the definition of cardiogenic shock

A

inadequate tissue perfusion primarily due to cardiac dysfunction

39
Q

what are the causes of cardiogenic shock?

A

MI HEART

MI
hyperkalaemia (inc electrolytes)
endocarditis- valve destruction
aortic dissection 
rhythm disturbance
tamponade 
obstructive- tension p neumo, massive PE
40
Q

what is the presentation of cardiogenic shock?

A

unwell, pale, sweaty, cyanosed, distressed
cold clammy peripheries
tachycardia/pnoeic
pulmonary oedema

41
Q

what are the causes of tamponade

A 
trauma
lung/breast cancer
pericarditis
MI
bacteria eg TB
42
Q

what are the signs of tamponade

A

beck’s triad- low bp, raised jvp, muffled heart sounds

kussmaul’s sign- raised jvp on inspiration

pulsus paradoxus- pulse fades on inspiration

43
Q

what investigations do you do in tamponade?

A

echo- diagnostic

CXR- globular heart

44
Q

what is the management of tamponade?

A

ABCs

pericardiocentesis- under echo guidance

45
Q

what is stage 1 HTN

A

> 140/90

46
Q

what is stage 2 HTN

A

> 160/100

47
Q

what is severe HTN

A

> 180/110

48
Q

what is malignant HTN

A

> 180/110 + papilloedema +/or retinal haemorhage

49
Q

what is isolated SHT

A

systolic >/ 140, diastolic <90

50
Q

what is the aetiology of HTN?

A

PREDICTION
primary- 95%
renal- RAS, GN, APKD, PAN
endo- high T4, cushings, phaeo, acromegaly, conn’s

drugs- cocaine, NSAIDs, OCP, steroids
ICP high 
CoA- coarcation of aorta
toxaemia of pregnancy PET
increased viscosity 
overload with fluid
neurogenic- diffuse axonal injury, spinal section
51
Q

what symptoms/signs could you see with HTN that could suggest its cause?

A 
high HR- thyrotoxicosis 
RF delay- CoA
renal bruit- RAS
palpable kidneys- APKD
paroxysmal headache, tachycardia, sweating, palps, labile or postural hypotension- phaeo
52
Q

what end-organ damage can HTN cause? (categories)

A 
CANER
cardiac
aortic
neuro
eyes- hypertensive retinopathy
renal
53
Q

what end-organ damage can HTN cause to the heart?

A

IHD
LVH leading to CCF
AR
MR

54
Q

what end-organ damage can HTN cause to the aorta

A

aortic dilation leading to AR + dissection

aneurysm
dissection

55
Q

what end-organ damage can HTN cause to the brain?

A

CVA- ischaemic, haemorrhagic

encephalopathy (malignant HTN)

56
Q

what end-organ damage can HTN cause to the eyes?

A 
hypertensive retinopathy
Keith-Wagener classifcation::
1. tortuosity and silver wiring
2. AV nipping
3. flame haemorrhages+ cotton wool spots 
4. papilloedema

grades 3 +4= malignant HTN

57
Q

what end-organ damage can HTN cause to the kidneys?

A

proteinuria

CRF

58
Q

what investigations would you conduct for HTN?

A

1) 24h ABPM- then treat unless severe HTN
2) urine- haematuria, ab:cr ratio
3) bloods- fbc, u+e eGFR glucose fasting lipids
4) 12 lead ECG- LVH, old infarct
5) calculate 10yr CV risk

59
Q

what is the lifestyle management for HTN?

A 
more exercise
smoking cessation 
less alcohol
less salt
less caffeine
60
Q

what are the indications for pharmacological management of HTN?

A

1) stage 2 HTN >160/100
2) severe/malignant HTN - specialist referral
3) consider specialist if <40yo with stage 1 HTN + no end organ damage
4) <80yo stage 1 and one of:
target organ damage
10yr CV risk >/20%
established CVD
DM
renal disease

61
Q

what is BP target for <80yo patients?

A

<140/90

62
Q

what is BP target for <80yo with DM?

A

<130/80

63
Q

what is BP target for >80yo patients?

A

<150/90

64
Q

what is the CV risk management in HTN?

A

statins for primary prevention if 10yr CVD risk >/20%

aspirin- evaluate risk of bleeding

65
Q

how would you manage malignant HTN?

A

1) controlled decrease in BP over days to avoid stroke
2) atenolol or long-acting CCB PO
3) encephalopathy/CCF: frusemide + nitroprusside/laetalol IV with aim to decrease bp to 110 diastolic over 4h
- nitroprusside needs intra-aterial bp monitoring

66
Q

what medications by stage for HTN management <55yo white?

A

1st) ACEi or ARB
2nd) ACEi/ARB + CCB
3rd) ACEi/ARB + CCB + thiazide-like diuretic
4th) RESISTANT HTN- so ACEi/ARB + CCB + diuretic + another diuretic eg spiro OR alpha or beta blocker
seek expert opinion

67
Q

what medications by stage for HTN management >55yo or black?

A

1st) CCB (or thiazide-liked diuretic)
2nd) CCB + ARB (over ACEi in black people)
3rd) CCB + ARB + thiazide-like diuretic
4th) resistant HTN so CCB + ARB + thiazide diuretic + further diuretic or alpha/beta blocker
seek expert opinion

68
Q

why would you want to avoid thiazide-like diuretics and beta blockers if you can in HTN management?

A

increases rsk of diabetes

69
Q

when would you consider using beta blockers to control HTN?

A

it is used 4th line for resistant HTN but only consider if young and ACEi/ARB not tolerated

CARDIO (10 decks)

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